Provider Demographics
NPI:1861671216
Name:SURA, ISHITA N (PT)
Entity Type:Individual
Prefix:
First Name:ISHITA
Middle Name:N
Last Name:SURA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 SAN FELIPE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95135-1546
Mailing Address - Country:US
Mailing Address - Phone:408-841-7203
Mailing Address - Fax:
Practice Address - Street 1:20823 STEVENS CREEK BLVD
Practice Address - Street 2:#200
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-2108
Practice Address - Country:US
Practice Address - Phone:408-252-6076
Practice Address - Fax:408-252-1159
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39318225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA39318OtherLICENSE